The Contribution of a National Network of Social Observatories to Improving Population Health
Authors: Christine Bachrach, Nancy Adler, Lindsay Chase-Lansdale, Sandy Hofferth, and Van Tran.
Comments welcome; also potential collaborators. Contact: Christine A. Bachrach, University of Maryland. chrisbachrach@gmail.com
The United States spends more money on health care than any other advanced economy, yet our population experiences far worse health and higher rates of mortality at all ages up to age 65 than other “peer” nations with similar economies. A recent report from the Institute of Medicine provides the most recent evidence: Americans have higher age-adjusted death rates than populations in 16 other peer countries and fare worse with respect to a large number of health conditions, including infant mortality, low birth weight, injuries and homicides, adolescent pregnancy and sexually transmitted infections, HIV and AIDS, drug-related deaths, obesity and diabetes, heart disease, chronic lung disease, and disability. According to the IOM, “America's health disadvantage probably results from a combination of factors: inadequate health care systems, unhealthy behaviors, social and economic factors, and environmental factors, such as metropolitan landscapes that encourage car use rather than exercise.”[1] This finding echoes many other reports and studies that point to social and behavioral factors as the leading causes of America’s poor health.[2]
Unfortunately, the case for the social and behavioral causes of health is not universally appreciated. On February 5, 2013, House Majority Leader Eric Cantor told an audience at the American Enterprise Institute that “funds currently spent by the government on social science would be better spent finding cures for diseases.” The U.S. is a world leader in finding biological cures for disease, but the health of its population lags far behind other advanced economies. Even when cures are found in the lab, implementing them effectively and ensuring that they work in all places and groups require an understanding of social and behavioral determinants of health and how they can be modified. Instead of portraying social science and health research as adversaries, as Cantor does, we should be moving to integrate them behind the cause of improving health.
The Observatory project can help us do this by addressing data limitations that have hampered population health research. Population health research is an interdisciplinary field that seeks to characterize, explain and/or influence the levels and distributions of health within and across populations. Population health researchers view health as the product of multiple determinants at the biologic, genetic, behavioral, social, and environmental levels and their interactions among individuals and groups and across time and generations. Thus, the field addresses the multiple interacting factors which lie “upstream” to disease onset and progression and examines how they could be modified to improve population health and ameliorate health disparities. The field addresses health outcomes, health determinants, and policies and interventions that link the two (Kindig & Stoddart, 2003).
A national network of integrated social science data centers (“social observatories”) could make unprecedented contributions to strengthening population health research and improving population health.
- The approach being developed by the observatories project is inherently multi-level. Existing plans already cover many of the independent variables that population health researchers consider significant as upstream determinants of health: environmental conditions, built environments, public policies, social integration and civic engagement, socioeconomic characteristics of the population as well as opportunity and mobility in the community, the family and early experiences, behavioral patterns as well as social and built features of the community that shape behavioral and social patterns (for example, tobacco regulation, food environments, violence exposure and transportation systems). Population health researchers could learn a great deal simply from what is already envisioned using common health outcomes. However, given recent advances in available biomarkers and sensors, they could also go further to develop data that could link these social and behavioral factors to the biological processes that produce health and disease. This could be done through alliances with local public health officials and health care providers and/or special-purpose surveys.
- The local-but-national design of the project is also ideally suited to the needs of population health researchers. If “all politics is local,” so is improving population health. Communities need information about how their local environments impact the health of their populations in order to make effective choices about potential interventions. At the same time, national policies that affect health also need this kind of information across a wide diversity of communities. The design of this project allows research that can be useful at both levels; it offers the opportunity for comparative community studies that can provide essential information on how local environments influence the impact of different upstream factors on individual health.
- The Affordable Care Act requires nonprofit hospitals to engage in community health planning; to make investments in the communities they serve; and to demonstrate results. The law also provides incentives for businesses to develop wellness programs for their employees (Rosenbaum 2011). This should foster local community partnerships that engage both business and hospitals and health systems in population health research allowing each to better characterize the pathways that are creating health and disease in their communities, “from cells to society.” The development of these partnerships, in turn, would greatly facilitate the development of effective population health policy.
As suggested above, creating a health component of the Observatory project could bring in data that might not otherwise be available, such as anonymized information from health care providers. For example, the London Health Observatory in Great Britain collects data from hospital admissions and outpatient records, ambulance services, and primary care and mental health providers. The development of electronic health records will facilitate this type of data sharing, although issues relating to privacy and human subjects will need strict attention. A second data resource would be hybrid survey designs that sample from patients in health care settings as well as community residents in general, collecting detailed health histories that transcend particular providers, biological markers of disease pathways, and individual-level experience with various aspects of the community environment (e.g., employment, health care, church attendance, use of community services, residence history, and subjective accounts of experience).
Many local public health agencies in the US already collect and provide access to a wide range of administrative and survey data, which are available at multiple levels of geographical units. For example, the New York City Department of Health and Mental Hygiene has been conducting the annual Community Health Survey since 2002, covering a wide range of health outcomes and health behaviors. It also provides access to vital statistics, details on healthcare facilities and health service providers, etc. Similarly, the New York State Department of Health has access to a range of restricted data on claims submitted and processed by healthcare providers, which provide a detailed snapshot of healthcare consumption and healthcare-seeking behaviors across diverse patient populations.
Together with the data now being envisioned by the Observatory project, these health-related data would enable integrative interdisciplinary studies of population health. Some examples might include:
- studies documenting the influence of specific upstream factors on health within and across communities;
- studies identifying the most important factors producing health-deleterious behaviors and inhibiting healthy behaviors within particular settings;
- studies investigating how the influence of upstream factors differs across racial/ethnic, age, SES, gender, and residential groups;
- studies identifying new linkages between environmental/contextual factors and health outcomes, the biological pathways that mediate these, and possible genetic moderators, noting particular time periods in the life course;
- studies of how federal policy may differentially affect the health of community populations and the mediating pathways that produce such variation; and
- intervention (design & evaluation) studies that tailor health improvement strategies to local community settings and available resources.
Development of a health component for the Observatory project would require significant investment in building coalitions with medical providers and public health experts; developing appropriate procedures to ensure that human subjects are protected and the project earns the trust of both individuals and communities; investigating the extent to which health data could be available at various levels of aggregation, from the individual to the census tract; overcoming computational challenges to integrating data; and much more. Yet the payoff of such an effort would be immense, providing a tool for collaboration across the social sciences and biomedical sciences that could potentially change the nation’s dismal course on health.
[1] http://sites.nationalacademies.org/DBASSE/CPOP/US_Health_in_International_Perspective/index.htm#.UchwzVXD-h0, Accessed 6-24-13
[2] E.g., the Robert Wood Johnson Foundation’s Commission to Build a Healthier America (http://www.commissiononhealth.org/); McGinnis & Foege, 1993; Mokdad, et al., 2004; 2005; Schroeder, 2007; World Health Organization, 2008; National Research Council 2011.
References
Kindig, David and Greg Stoddart. . What is population health? American Journal of Public Health 93(3):380-383.
McGinnis JM, Foege WH. 1993. Actual causes of death in the United States. Journal of the American Medical Association 270:2207-2212.
Mokdad, A.H., Marks, J.S., Stroup, D.F., and Gerberding, J.L. (2004). Actual causes of death in the United States, 2000. Journal of the American Medical Association, 291(10), 1238-1245.
Mokdad, A.H., Marks, J.S., Stroup, D.F., and Gerberding, J.L. (2005). Correction: Actual causes of death in the United States, 2000. Journal of the American Medical Association, 293, 293-294.
National Research Council (2011) International Differences in Mortality at Older Ages: Dimensions and Sources. Panel on Understanding Divergent Trends in Longevity in High-Income Countries. National Academies Press: Washington, DC
Robert Wood Johnson Foundation Commission to Build a Healthier America, 2009. Executive Summary: Beyond Health Care: New Directions to a Healthier America.http://www.commissiononhealth.org.
Rosenbaum, Sara, 2011. The Patient Protection and Affordable Care Act: Implications for Public Health Policy and Practice. Public Health Rep. Jan-Feb; 126(1): 130–135.
Schroeder, Steven A. (2007) We Can Do Better – Improving the Health of the American People. New England Journal of Medicine. September 2007. 1221-1228.
World Health Organization. 2008. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Final Report of the Commission on the Social Determinants of Health.
